The Cluster-Randomized BRIGHT Trial: Proactive Case Finding for Community-Dwelling Older Adults

Ngaire Kerse; Chris McLean; Simon A. Moyes; Kathy Peri; Terence Ng; Laura Wilkinson-Meyers; Paul Brown; Nancy Latham; Martin Connolly

doi:10.1370/afm.1696

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Lack of effect in proactive identification of older people at risk of functional decline
Jeanet W. Blom

Published on: 19 December 2014
Author response: BRIGHT may be successful in other health systems
Ngaire Kerse

Published on: 01 December 2014
Commentary on Kerse et al.
Jennifer S Lin

Published on: 26 November 2014

Published on: (19 December 2014)
Page navigation anchor for Lack of effect in proactive identification of older people at risk of functional decline
Lack of effect in proactive identification of older people at risk of functional decline
Jeanet W. Blom, Associate Professor.
Other Contributors:
Identifying older people at high risk for disability, followed by a plan to improve care and maintain or improve daily functioning, is intuitively felt to be the right thing to do in the care for older persons. Although this type of intervention has shown to have a positive, albeit a small, effect on clinical outcomes (e.g. a reduction in nursing home admission), the review of Beswick et al. noted that studies performed...
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Identifying older people at high risk for disability, followed by a plan to improve care and maintain or improve daily functioning, is intuitively felt to be the right thing to do in the care for older persons. Although this type of intervention has shown to have a positive, albeit a small, effect on clinical outcomes (e.g. a reduction in nursing home admission), the review of Beswick et al. noted that studies performed after 1993 no longer showed a positive effect (1).
More recent studies in the Netherlands also failed to show a direct effect on healthcare use, and on functioning and quality of life (2,3). It seems that in countries with well-organised primary care, an attempt to identify older people at increased risk for disability, followed by a comprehensive care plan, is a redundant intervention. However, similar interventions in countries with less integrated primary care systems, such as the United States, have also shown limited success (4, 5).
The lack of effectiveness of this type of intervention might be related to the following: Was the right group of patients selected, i.e. those at high risk for disability and with a substantial chance to benefit from the intervention? Was the penetration of the intervention on a large enough scale? Similar to younger people, are older people also reluctant to respond to unsolicited healthcare offers (6)? Do we know which group is the most appropriate to identify? Who are at greatest risk to develop disability and who have the greatest chance to improve? Perhaps there is an effect among certain subgroups that we are not yet able to identify, or perhaps only certain components of the reported interventions have positive results? Thus, this remains a large and open area for investigation, which can contribute to optimalisation of daily functioning in old age (7).
It is important to realise that the outcome measures most often used to assess functioning and quality-of-life, do not necessarily reflect the individual goals and priorities of older persons (8-10). These outcome measures are often general and not always suitable to measure changes among older people, with their individual differences in character and abilities. Since this type of intervention generally includes a comprehensive assessment aiming to be followed by an individualised intervention, outcome measures should also reflect individual goals and priorities. Such outcomes are available and should be further developed (11, 12).
However, since a large number of similar trials has been performed, this might indicate that the effect of such changes in the organisation and provision of health care on the overall functioning and quality-of-life of older people, is not as large as one would expect or hope it to be. In fact the effect might be more reflected in process outcomes, such as continuity of care - an item which is not usually measured. The perceptions of older people themselves, and their caregivers, about the type of care are also important, although these are often considered to be 'soft' outcomes. Perhaps functioning, participation, and the quality-of-life of older persons are more likely to be influenced by social or community interventions, such as age-friendly housing and age-friendly community activities. Organisational interventions in health care for older persons are still highly relevant, but should be evaluated by measuring a wider range of different outcomes.
References
1. Beswick AD, Rees K, Dieppe P, Ayis S, Gooberman-Hill R, Horwood J, Ebrahim S. Complex interventions to improve physical function and maintain independent living in elderly people: a systematic review and meta-analysis. Lancet. 2008 Mar 1;371:725-35.
2. Metzelthin SF, van Rossum E, de Witte LP, Ambergen AW, Hobma SO, Sipers W, Kempen GI. Effectiveness of interdisciplinary primary care approach to reduce disability in community dwelling frail older people: cluster randomised controlled trial. BMJ. 2013 Sep 10;347:f5264.
3. Janse B, Huijsman R, de Kuyper RD, Fabbricotti IN. The effects of an integrated care intervention for the frail elderly on informal caregivers: a quasi-experimental study. BMC Geriatr. 2014 May 1;14:58.
4. Lin JS, Whitlock EP, Eckstrom E, Fu R, Perdue LA, Beil TL, Leipzig RM. Challenges in synthesizing and interpreting the evidence from a systematic review of multifactorial interventions to prevent functional decline in older adults. J Am Geriatr Soc. 2012 Nov;60:2157-66.
5. Boult C, Leff B, Boyd CM, Wolff JL, Marsteller JA, Frick KD, Wegener S, Reider L, Frey K, Mroz TM, Karm L, Scharfstein DO. A matched-pair cluster-randomized trial of guided care for high-risk older patients. J Gen Intern Med. 2013 May;28:612-21.
6. van der Weele GM, de Waal MW, van den Hout WB, de Craen AJ, Spinhoven P, Stijnen T, Assendelft WJ, van der Mast RC, Gussekloo J. Effects of a stepped-care intervention programme among older subjects who screened positive for depressive symptoms in general practice: the PROMODE randomised controlled trial. Age Ageing. 2012 Jul;41:482-8.
7. Mayo-Wilson E, Grant S, Burton J, Parsons A, Underhill K, Montgomery P. Preventive home visits for mortality, morbidity, and institutionalization in older adults: a systematic review and meta-analysis. PLoS One. 2014 Mar12;9:e89257.
8. Reuben DB, Tinetti ME. Goal-oriented patient care--an alternative health outcomes paradigm. N Engl J Med. 2012;366:777-9.
9. Gill TM, Feinstein AR. A critical appraisal of the quality of quality-of-life measurements. JAMA. 1994 Aug 24-31;272:619-26.
10. Hickey A, Barker M, McGee H, O'Boyle C. Measuring health-related quality of life in older patient populations: a review of current approaches. Pharmacoeconomics. 2005;23:971-93.
11. Rockwood K, Stolee P, Fox RA. Use of goal attainment scaling in measuring clinically important change in the frail elderly. J Clin Epidemiol. 1993;46:1113-8.
12. Wright JG, Young NL. The patient-specific index: asking patients what they want. J Bone Joint Surg Am. 1997;79:974-83.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (1 December 2014)
Page navigation anchor for Author response: BRIGHT may be successful in other health systems
Author response: BRIGHT may be successful in other health systems
Ngaire Kerse, Professor
Other Contributors:
The authors thank Dr Lin for her thoughtful response and agree that the BRIGHT tool, which was successful in identifying those with unmet need, may be effective if the second step of the case finding process is sufficiently different compared with the control group. A differential response may be more likely in health systems where the background services are less integrated and organised than in New Zealand. A similar...
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The authors thank Dr Lin for her thoughtful response and agree that the BRIGHT tool, which was successful in identifying those with unmet need, may be effective if the second step of the case finding process is sufficiently different compared with the control group. A differential response may be more likely in health systems where the background services are less integrated and organised than in New Zealand. A similar trial design, with detailed personal outcomes and health service related process and outcome measures would be necessary to show such impact.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (26 November 2014)
Page navigation anchor for Commentary on Kerse et al.
Commentary on Kerse et al.
Jennifer S Lin, Associate Director
Dr. Kerse and colleagues recently published results from their large, well-conducted, pragmatic trial designed to see if case-finding using a brief geriatric screening instrument to identify at-risk older adults could reduce hospitalizations and improve patient function and quality of life. Although implementation of the risk assessment tool in New Zealand did not have a clinically important impact on a priori specified...
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Dr. Kerse and colleagues recently published results from their large, well-conducted, pragmatic trial designed to see if case-finding using a brief geriatric screening instrument to identify at-risk older adults could reduce hospitalizations and improve patient function and quality of life. Although implementation of the risk assessment tool in New Zealand did not have a clinically important impact on a priori specified outcomes, this trial and the thoughtful nature of reporting of the trial and its findings are an important contribution to the geriatric health assessment and management literature base.
First, this study illustrates the importance of robust reporting around baseline characteristics as it pertains to understanding risk of poor outcomes in older adults. Older adults represent a very heterogeneous group of individuals, more so than younger or middle-aged adults. Detailed baseline characteristics allow us to understand that the BRIGHT trial included a fairly specific population, that is a relatively healthy and educated very old (mean age 80 years) population, the majority of whom were married and not receiving any home help. Arguably this population may not be applicable to the larger geriatric population seeking primary care.
Second, this study illustrates why it is crucial to understand "usual care" control groups, which are often not well described in publications. New Zealand has a integrated primary care system with nearly full coverage of older adults, with publicly funded community services and geriatric specialist multi-disciplinary teams. It may be difficult to improve upon these services if primary care is functioning well and sending higher risk older adults onto these services already. It is also apparent that these "usual care" services are not routinely available in the US, and that a brief assessment identifying older adults for more intensive services might be of high value and great clinical impact in other settings.
Third, this trial utilizes a constellation of important clinical outcomes. Using multiple outcomes measures health utilization as well as important patient outcomes (functional ability and quality of life) are important to evaluate in tandem. A priori specification of primary and secondary outcomes assures us that selective reporting is unlikely. Last, reporting serial measurement of outcomes at baseline and over time, allow us to understand that over the three year trial, there was not a clinically significant increase in hospitalizations, or decrease in function or quality of life over time in either group. This information again suggests a relatively healthy population and robust geriatric care in both the control and intervention groups.
This publication demonstrates the importance of intelligent and thorough reporting, and how this impacts our ability to assess why certain interventions may not demonstrate a clinically important impact despite their face validity.
Sincerely, Jennifer S. Lin, MD, MCR, FACP
Competing interests: None declared
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Competing Interests: None declared.